Gonorrhea detecting

ABSTRACT

Laboratory identification of Neisseria gonorrhoeae is facilitated through distribution of sterile, self-administrable, fibrous catamenial swab devices, transportable containers and holding media to asymptomatic individuals for anonymous use and submission of subculture specimen samples to a clinical testing station. The containers are marked with coded references which allow the individual or her authorized representative to anonymously inquire as to the determination made on the transported swab specimen at the clinical testing station. The holding medium is composed of phosphate-buffered saline with ethanol, a secondary protein derivative, progesterone, starch, agar, antibiotics and bicarbonate, in a semi-solid gel.

United States Patent [191 Thomas, Jr. et al.

[ GONORRHEA DETECTING [75] Inventors: Charles A. Thomas, Jr., Newton; James E. Zuckerman, Jr., Acton; Stephen A. Morse, Brockton, all of Mass.

[73] Assignee: Charles A. Thomas, Jr., Newton,

Mass.

[22] Filed: Mar. 30, 1973 [2]] Appl. No.: 346,415

[4 1 May 13, 1975 3,743,579 Zilberblat 195/100 X [57] ABSTRACT Laboratory identification of Neisseria gonorrhoeae is facilitated through distribution of sterile, selfadministrable, fibrous catamenial swab devices, trans portable containers and holding media to asympto- [521 195/100; 95/99; l95/l0l; matic individuals for anonymous use and submission 195/102 of subculture specimen samples to a clinical testing [51] Int. Cl Cl2k l/IO Station The Containers are marked with coded f [58] held of Search 195/99 ences which allow the individual or her authorized 95/103 representative to anonymously inquire as to the determination made on the transported swab specimen at References cued the clinical testing station. The holding medium is UNITED STATES PATENTS composed of phosphate-buffered saline with ethanol, a 3,170339 2/1965 o 195/|00X secondary protein derivative, progesterone, starch, 1467.579 9/1969 Bianchi et alum l95/l00 x agar, antibiotics and bicarbonate, in a semi-solid gel. 3,625,833 l2/l97l Schaffer I95/l00 X 8 Cl 2 D 3.715281 2/1973 Martin et al. 195/100 x A 14c I i 2 I is A 876-73 7H g a X d I r, 14

GONORRHEA DETECTING BACKGROUND OF THE INVENTION The present invention relates in general to clinical diagnosis of gonnorrhea and more particularly to holding media for transporting Neisseria gonnrrhoeaesuspect specimens.

The reported incidence of the veneral disease, gonorrhea. has been increasing by more than percent per year in the United States and the per capita rate thereof reported for 1970 is higher than the previous all-time high rate reported in 1947. The World Health Organization estimates that, worldwide, more than a hundred million new cases of gonorrhea are recorded annually and the global incidence of the disease has reached pandemic proportions.

Despite increasingly liberal social mores regarding frank discussion of sexual contacts, sufficient social stigma remains attached to veneral diseases that many cases treated by private physicians are unreported for public health purposes and many patients are too embarrassed to even seek diagnosis in the first instance. The problem is magnified because more than 80 percent of infected women, and about 10 percent of infected men, are asymptomatic. Commonly used diagnostic methods for the disease include culturing of swab specimen samples in media, which are selective for the growth of Neisseria gonorrhoeae. A serious problem is the shoft life of the organisms outside the infected person. Specimens must be cultured promptly after sampling.

Transport and holding media have been used to maintain the organisms in a viable state during transport from a sampling location to a distant laboratory or to accommodate a waiting period between sampling and bacteriological diagnosis in the same laboratory. The known media include (a) Stewart's Transport Medium which, per se and in the charcoal-added Amies modification thereof, comprises a saline solution buffered with phosphates and having a small amount of agar, and a small amount of sodium thioglycolate reducing agent therein and (b) Transgrow [registered U.S. trademark of the United States Government] growth medium, which comprises a nutritive medium including hemoglobin modified by addition of the antibiotic inhibitor, trimethoprim lactate. The latter medium is packaged in containers which have a special atmosphere including an increased percentage of carbon dioxide therein. Transgrow has to be incubated overnight to grow colonies after inoculation of a specimen thereon.

It is an important object of the invention to provide an improvement in gonorrhea detection which overcomes one or more of the problems enumerated above.

It is another objective of the invention to achieve this goal in a manner which avoids embarrassment to a potentially infected person who is submitting a sample.

It is a further object of the invention to extend the available transport holding time for sample specimens.

It is a further object of the invention to provide an improved holding medium which maintains virulent gonococci for long periods of time, in excess of two days.

it is a further object of the invention to provide a simple holding medium consistent with one or more of the preceding objects.

It is a further object of the invention to simplify transport containers for specimens and holding containers therefor consistent with one or more of the preceding objectives.

SUMMARY OF THE INVENTION According to the invention, a liquid holding medium for Neisseria gonorrhoeae-suspect swab specimens containing phosphate-buffered saline having a pH of 7.l to 7.3. Preferably the medium contains secondary protein derivative components in non-nutritive concentration and preferably also contains ethanol and/or the hormone, progesterone. Preferably. the medium also comprises selective antibiotics, to avoid culture overgrowth by commensals, agar, soluble starch, and other nonnutritive ingredients which are, per se, conventional holding medium components.

A preferred medium also includes a dissolved source of carbon dioxide. This source preferably comprises an ammonium or alkali metal or alkaline earth metal bicarbonate salt selected from the class consisting of Nal-lCO Lil-[C0 KHCO NH,HCO and Ca(H- sh- Mailable containers, at least partially filled with such holding media are distributed to patient sampling locations. The containers are marked with code indicia to allow tracing and correlation while preserving the personal anonymity of the patient. Swab specimens are obtained from patients and immersed in the medium. The containers are then sealed and transported to a central testing station for bacteriological, physical or chemical evaluation. The patient or her authorized representative, such as a nurse or physician, can telephone to the testing station giving the code number and receive the report of whether the culture was positive or negative for Neisseria gonorrhoeae and, if positive, a recommendation to obtain treatment.

As used herein, the following terms have the following meanings unless otherwise indicated at any location thereof.

Swab specimens refers to swab applicators, catamenial devices, intrauterine sponge biopsy devices, biological loops and the like.

Simple proteins, conjugated proteins, derived proteiris including primary derived proteins and secondary protein derivatives are used in the same sense as defined by the American Physiological Society and the American Society of Biological Chemists to classify proteins. In particular, secondary protein derivatives are protein derivatives obtained through hydrolytic cleavage and include proteoses, peptones and peptides.

Although pronoun references to patients are in the female gender, male patients are also contemplated and "her" or she" includes men unless otherwise indicated.

Other objects, features and advantages of the invention will be apparent from the following detailed description of preferred embodiments of the invention, taken in connection with the accompanying drawing, in which BRIEF DESCRIPTION OF THE DRAWING FIG. I is a graphical representation of organism population vs. time; and

FIG. 2 is a partially sectioned view of a transport container, according to a preferred embodiment of the invention.

Detailed Description of Preferred Embodiments In a preferred holding medium, the salt solute components are K HPO KH PO and NaCl. The proportions of all components are:

Progesterone Ulll gm/litcr solution a secondary protein {Difco Corp. Protcose Peptone No. 3] \S.0U gm/litcr solution leg. vancomycin 3 l[l grn/litcr solution] Higher amounts may be used for other antibiotic choices, e.g., colistin or nystatin, balance liquid comprising 1 volume percent (nominal) ethanol, 99 percent water.

The sodium bicarbonate and antibiotics are added to the medium after autoclaving. The ethanol and progesterone are added to the medium just before autoclaving. Thus the actual ethanol concentration may be less than 1 percent due to evaporation, but is above 0.5 percent.

The medium has held gonococci (gc) viable in high numbers for over 600 hours in repeated tests at 37C and for over 72 hours (3 days) at 25C.

The antibiotics and other inhibitors are preferably selected from the group consisting of uancomycin, fungizone, colistin and mixtures thereof. The gonococci survival is per se unaffected by the antibiotics and other inhibitors by holding their concentrations low enough in accordance with criteria well known per se in the art. But the antibiotics suppress overgrowth by such commensals as Candida albicans, Staphylococcus aureus, and Escherichia coli.

The antibiotic concentration (in g/l) would be 7.5 X for colistin and 12.5 X 10- for Nystatin. The antibiotic components are tailored to the sampling site throat. cervix, rectum, urethra. Other inhibitors which may be employed include chelating agents such as sodium salts of ethylenediamenetetracetic acid (EDTA) to chelate heavy metal ions and calcium. Remove of calcium inactivates lysozyme which would otherwise lyse the specimen bacteria [i.e;, rupture the cells].

The protein component is preferably an acid or enzymatic hydrolysate of a protein which is depleted of salt after hydrolysis thereof to reduce salt concentration below levels fatal to organisms.

Preferably casein is used as primary starting protein.

The agar component forms the solution to a loose gel so that specimens stay on a swab, for ease of testing, rather than spread through the medium. Yet the swab can be inserted into the gel. The starch binds impurities of the agar or otherwise introduced impurities and may be eliminated when very pure agars and other solution components are used.

The bicarbonate provides the necessary source of bicarbonate convertable by natural processes to carbon dioxide for carbon dioxide fixing, life-sustaining processes of the bacteria and further, in concentration up to about 400 micrograms/ml, the bicarbonate reduces lag time.

The progesterone and ethanol have each been found to contribute to bacteria maintenance. The ethanol also serves as a progesterone solvent.

A preferred holding medium preparation procedure is as follows;

l. weigh out and dissolve the phosphate and NaCl salts and peptone in water in over concentrated (2XNormal) solution;

2. dissolve the starch in 100 ml. hot water;

3. mix the two solutions;

4. weigh out and add the agar;

5. heat to boiling to place the agar in solution;

6. add water to dilute to normal concentration at a temperature above solidifying temperature (45C);

7. prepare a 10 ml. percent ethanol in water solution and dissolve the progesterone therein and add to the solution of (6);

8v autoclave (7) 15 minutes, 15 psi, 121C;

9. cool, but before reaching gelling temperature add the antibiotics and a 4 percent bicarbonate solution;

l0. measure out aliquots of solution into vials or tubes and seal asceptically.

It has also been discovered in connection with making the present invention that many conventional swab fibers are toxic to gonococci. Fatty acid fiber coatings are believed to be the principal deleterious agent. In any case, fibers for swab devices for use in holding media can be rendered non-toxic by charcoal treating as follows. An acid free slurry containing 20 percent of activated charcoal (by volume) in water is prepared and boiled with the swabs for l0 minutes. The swabs are then removed and washed to remove surface traces of charcoal.

The following non-limiting examples are illustrative of the effective holding times afforded by the holding medium of the invention in connection with various fibrous swab devices used for sampling.

Laboratory strains of gonococcus were grown in broth; spun washed and suspended in a broth or the holding medium described above with and without progesterone (+1 or P). Swabs with different fiber components described below were dipped into the suspension and then stored at room temperature (25C) or 37C. Samples were removed from storage at different times and observed for positive or negative Neisseria indication determined visibly by observation of colonial morphology and checked, as necessary, by oxidase testing. The results are indicated as positives/total sampled fractions at the various storage time periods of sampling in Tables l & ll below.

The underlying mechanisms of the improvements af forded by the present invention are not wholly understood, but are associated with a flattening depression of the usual characteristic graphical representation of bacteria population (colony) forming units) with time. Such graphs normally display a lag phase followed by a period of exponential rate growth followed by transistion and stationary plateau phases TABLE I Holding Medium Suspended TABLE l-Continued Holding Medium Suspended Cotton R.T. 37C Hours +P P +P -P TABLE [1 Holding Medium Suspended 37C Charcoal Treated Cotton Rayon Cotton Hours +P +P +P 0 4/4 414 6/4 4 4 4/4 4/4 45 6/6 6/7 6/7 7/7 7/7 7/7 91 6/7 6/7 4/7 7/7 6/6 6/6 140 7/7 6/7 2/7 7/7 7/7 4/7 Hours Room Temperature and then by an exponential rate decaying death phase.

The holding medium of the present death phase can begin as a plateau given a sufficiently high innoculum and remains substantially flat until death phase. Alternatively a low innoculum can be introduced to the medium and experience lag and growth phases until reaching a stable plateau of population level. In the laymans terms, the medium of the present invention slowly starves the bacteria with a result of stable plateau-form population curve maintenance over an extended period of time while prior media overfeed the bacteria and induce catastrophic growth and early death associated with such growth. Variations of components and concentrations and other incidental conditions of the present invention can be tested for suitability by whether they compromise stability as indicated by the observed plateau characteristic.

Referring now to FIG. 1 of the drawing, there is shown a rough graphical representation, of the above discussed population-time characteristics, useful in understanding the principles of the invention. The linear abcissa is time in hours and the logarithmically scaled ordinate (CPU) is population of colony forming units of bacteria. The curves TM-l, TM-2, TM-3 show typical characteristics to be expected for prior art transport media and the curve GM shows typical characteristics to be expected for a growth medium starting with an innoculum of 10 units. Curves LHMl, LHMZ, LHM3, LHM4 are curves depicting characteristics to be expected from the present holding medium for innoculi of 10, 10 6X10 and 10, respectively.

Lag phases, growth phase (if any) and death phase for the respective curves are labeled and transition phase is the knee of the curves between lag and growth phases. All the curves are rough approximations and the alternative LHM death phases, which occur past 500 hours and over 1000 hours in some instances, are arbitrarily drawn. The effective population-time curve flattening of the present invention can be quantified as at least hours, for purposes of mail transport. The particular plateau level will depend on the protein selection and concentration and may be adjusted to suit the requirements of laboratory test methods.

Referring now to FIG. 2 of the drawing, there is shown an assembly of parts for a diagnostic kit comprising a catamenial device 10 such as tampon or Weck-cel sponge with applicator and a vial form container l2. Container 12 carries the holding medium. The dimensions of tube depend on whether a clinical swab or larger catamenial device is to be accommodated. A mail-transportable outer container 14 has a mail label 16. The container 12 has a label 18 with a tear-off tab 18. The label 12 and tab 18 have a common number for identification in an anonymous request for diagnosis and the tear-off tab also has a toll free laboratory phone number thereon.

A patient inserts the catamenial device or clinical swabs according to the instructions given with the kit (e.g., printed on the back of tab 20) to assure that an adequate sample is obtained. Typical instructions for a tampon device, for instance, would specify inserting the tampon into the vagina and allowing it to mremain there for 30 minutes to 24 hours.

The asceptically sealed vial is opened. The device is withdrawn and immediately placed in the holding medium and the vial 12 is resealed. Then tab 20 is removed, and the vial is placed in the mail container 12. The individual or her agent mails the container to the pre-addressed laboratory location printed at 16 on the container 14. Two to five days later, she calls the laboratory at a number indicated on the detached label tab and identifies herself by the unique identifying number on the detached label tab. The laboratory has the same number on the container 12.

The same procedure can, alternatively, be supervised by a private physician or nurse instead of leaving it to the patient.

The container 14 comprises an inner wall 14A, an outer wall 14B and a cap 14C. The vial 12 has a cap 22. Fibrous packing with thermal holding means therein is provided around the vial 12. Shock resisting insulating and thermal insulating material 26, such as polyurethane or polystyrene foam, is provided between walls 14A and 14B and also depending from cap 14C to press against vial 12 for secure positioning thereof.

The structure may also be simplified by eliminating the multi-wall structure thereof and/or combining the components 24, 26 and/or by using a single heavy walled container as both mail container and vial. However separate vial and container means are preferred. Reference to a mail transportable holding medium container herein refers to said vial and/or container.

It is preferred to hold temperature of the medium in vial 12 at a constant and preferably elevated level. Temperatures from 30 40C are preferred. This may be accomplished through electrical means, such as a resistance heater in the packing 24 and a battery and thermostat for controllably powering said heater, or chemically by use of heat of fusion of a two-phase composition of a hydrated salt soaked into the packing. Suitable salts and their heats of fusion (HF, in calories/- gram) and melting temperatures (T, in C) are:

TABLE III Salt HF T Na,HPO i2 mo sex 3m zniivo s mo 3 l .i 36.4 Na,iso. .in mo 51 1 3| One half to one and a half kilograms of hydrated salt would be used in connection with mailing usage of the container. Lesser amounts can be used for shorter periods of intra-clinic storage. The anhydride of the salt is stored and hydrated and heated to melt temperature and added to the container when the latter is ready for use.

It is evident that those skilled in the art. once given the benefit of the foregoing disclosure. may now make numerous other uses and modifications of. and departures from the specific embodiments described herein without departing from the inventive concepts. Consequently. the invention is to be construed as embracing each and every novel feature and novel combination of features present in. or possessed by. the apparatus and techniques herein disclosed and limited solely by the scope and spirit of the appended claims.

What is claimed is:

1. A holding medium for Neisseria gonorrhoeaesuspect specimens comprising a buffered saline solution. and

a non-nutritive concentration of secondary protein therein,

ethanol. dissolved in the solution. and

progesterone. dissolved in the solution.

whereby gonococci if present in the medium. display an essentially flattened and extended colon v forming-unit versus time-curve.

2. Composition of matter in accordance with claim 1 wherein said saline solution has a pH of 7.1 to 7.3.

and further comprising a source of bicarbonate ion in said solution.

3. Composition of matter in accordance with claim 2 wherein said saline solution comprises K HPO KH PO, and

NaCl as solute salts therein and is in a gel form. said source of bicarbonate is an alkali metal bicarbonate dissolved in said solution.

4. Composition of matter in accordance with claim 2 and comprising.

alkali metal bicarbonate as said source of carbonate.

agar

and a antibiotic component.

5. Composition in accordance with claim 4 comprising as proportions thereof at least i and no more than 20 grams of said protein per liter of solution.

at least 0.5 and no more than 2.0 grams of the mixed multiple salts per liter of solution.

agar in an amount effective to gel the solution.

antibiotics in an amount effective to prevent overgrowth by commensals.

balance a liquid volume of 0.5 to 1.5 volume per cent ethanol. balance water.

6. Composition in accordance with claim 4 wherein the protein is Proteose peptone No. 3 and the multiple salts are K,HPO KH PO and NaCl. the concentrations of solution components being .001 grniliter solution l.

balance of liquid comprising i percent by volume ethanol. 99 percent water.

7. Composition of matter in accordance with claim 1 and further comprising as solute components thereof.

alkali metal bicarbonate.

agar.

starch.

antibiotic. water.

8. Method of making a holding medium for .\'eisseria1 gonorrhoeae suspect specimens comprising the steps of preparing a buffered saline solution with a non nutritive concentration of secondary protein therein.

preparing a starch solution.

mixing said solutions to form a mixture.

adding agar to said mixture and boiling to dissolve the agar therein and cooling to a level above the solidification temperature of said agar solution. diluting to form a normal concentration solution. dissolving progesterone in ethanol and adding the progesterone/ethanol solution to said normal concentration aqueous solution.

heating to sterilize and reliquefy said gelled solution.

cooling said sterilized solution and adding an alkali metal bicarbonate and antibiotic components thereto at a temperature above the regelling temperature thereof. and

subdividing said solution into asceptically sealed aliquots.

a: 1 a in a: 

1. A HOLDING MEDIUM FOR NEISSERIA GONORRHOEAE-SUSPECT SPECIMENS COMPRISING A BUFFERED SALINE SOLUTION, AND A NON-NUTRITIVE CONCENTRATION OF SECONDARY PROTEIN THEREIN, ETHANOL, DISSOLVED IN THE SOLUTION, AND PROGESTERONE, DISSOLVED IN THE SOLUTION, WHEREBY GONOCOCCI IF PRESENT IN THE MEDIUM, DISPLAY AN ESSENTIALLY FLATTERNED AND EXTENDED COLONY-FORMING-UNIT VERSUS TIME-CURVE.
 2. Composition of matter in accordance with claim 1 wherein said saline solution has a pH of 7.1 to 7.3, and further comprising a source of bicarbonate ion in said solution.
 3. Composition of matter in accordance with claim 2 wherein said saline solution comprises K2HPO4, KH2PO4 and NaCl as solute salts therein and is in a gel form, said source of bicarbonate is an alkali metal bicarbonate dissolved in said solution.
 4. Composition of matter in accordance with claim 2 and comprising, alkali metal bicarbonate as said source of carbonate, agar and a antibiotic component.
 5. Composition in accordance with claim 4 comprising as proportions thereof at least 1 and no more than 20 grams of said protein per liter of solution, at least 0.5 and no more than 2.0 grams of the mixed multiple salts per liter of solution, agar in an amount effective to gel the solution, antibiotics in an amount effective to prevent overgrowth by commensals, balance a liquid volume of 0.5 to 1.5 volume per cent ethanol, balance water.
 6. Composition in accordance with claim 4 wherein the protein is Proteose peptone No. 3 and the multiple salts are K2HPO4, KH2PO4 and NaCl, the concentrations of solution components being
 7. Composition of matter in accordance with claim 1 and further comprising as solute components thereof, alkali metal bicarbonate, agar, starch, antibiotic, water.
 8. Method of making a holding medium for Neisserial gonorrhoeae - suspect specimens comprising the steps of preparing a buffered saline solution with a non-nutritive concentration of secondary protein therein, preparing a starch solution, mixing said solutions to form a mixture, adding agar to said mixture and boiling to dissolve the agar therein and cooling to a level above the solidification temperature of said agar solution, diluting to form a normal concentration solution, dissolving progesterone in ethanol and adding the progesterone/ethanol solution to said normal concentration aqueous solution, heating to sterilize and reliquefy said gelled solution, cooling said sterilized solution and adding an alkali metal bicarbonate and antibiotic components thereto at a temperature above the regelling temperature thereof, and subdividing said solution into asceptically sealed aliquots. 